November 17, 2015
Written by Arisa Mototake (class of 2015-2016)
I got to OA-2 at 6:50 and there were already 5 residents seated at the table. I politely said good morning but all I got in return was a stare. I sat at the table but felt very out of place. I now understood the urge to sit behind the wall. Dr. Harken walks in and starts his mini-lecture. Today he spoke about acute blood loss in trauma/surgery. He then posed a question, is this blood loss the same as anemia found in cancer, chemotherapy, critical illnesses or other chronic diseases. The residents remained silent. He then poses another question, “Does the number of hemoglobin make a difference or how you got there?” Dr. Harken then answers “We simply do not know”. He then continues to go through different experiments and statistical data and explains that many different patients respond better on the SF-36 when they have higher hemoglobin counts. SF-36 is a group of 36 questions to assess how happy/healthy you are. To wrap things up the goal of this lecture was to press that the goal of a physician was to make the patient feel better.
He quickly wrapped up lecture and I hurried over to him as he was about to leave. I introduced myself to him and he happily introduced me to Dr. Kara Rothenburg, a second year resident.
She looked a bit hesitant at first and told me that she had elsewhere to go afterwards. She quickly explained to me which OR she would be in and told me to meet her there. First time in the OR and now I had to find my way without sticking out like a sore thumb. I asked a cleaning lady where the front office was to get the vendor card for the futuristic scrub dispensing machine. I finally got to the office and asked for the vendor card. “Who are you?” the woman asked coldly. I quickly explained and she told me I had to leave a collateral for the card. Boy, was she intimidating. I quickly changed into my scrubs and headed on over to OR4. (After asking someone of course; I wasn’t going to risk becoming lost on the first day of my OREX)
The first procedure being done was an ICD placement for a 57 year old male suffering from Atrial Fibrillation and CHF (Congestive Heart Failure) with an ejection fraction (EF) less than 20%. EF is the percentage of blood that is pumped out from the heart with one contraction and is one of of the clinical indications of heart failure. A healthy individual will have an EF over 55 percent. This was a great surgery to start my OREX experience as I volunteer in the healthy hearts clinic with CHF patients. Many of our patients have pacemakers so being able to watch one being installed was incredible; I felt my volunteer experiences coming to a whole circle. I walked in and the patient was getting prepped for anesthesia. As fluoroscopy was going to be used I was instructed to wear a lead apron for protection. Dr. Harken walks in and explained the procedure to Kara. They were to insert a catheter through the superior vena cava and insert an electrode into the right ventricle to shock and pace. Kara showed me how to scrub in just in case I ever needed to but I reassured her I was only there to observe. Afterwards we re-entered the OR and the nurse taught me how to assist in gowning. At 8:29AM the patient was completely ready for the procedure and the first incision was made. Kara started cutting away and inserted her fingers to clear the connective tissue. I later saw that this was a pocket for the pacemaker. Kara then continued and inserted a needle below the clavicle for catheter insertion. This was rather a difficult task as she kept hitting the bone and was unable to get into the SVC. It took her many attempts but she was able to get it in successfully after putting in some contrast dye and visualizing it via fluoroscopy. The next couple steps for getting the electrode in was a tad confusing but involved multiple tubings and some pushing and pulling (excuse my crude explanation). But the electrode was placed and a technician was present to check on the signal. The numbers from the signal were stable, and the electrode was fastened and tightened and hooked up to the pacemaker. It was then tucked into the pocket made previously and sutured shut. After the surgery, Kara needed to go to the ICU and so she introduced me to a different resident, Dr. Francisca Maertens.
The next procedure being done was an arteriovenous fistula. This procedure is normally done for patients with end stage renal disease to make an easier access point for dialysis. The procedure first starts with searching for the venous target. It normally is done on the wrist but this time Francisca and Dr. Harken decided to use the area right above the elbow as the vein was easier to find there. As the incision was made and the target was found, the vein was surrounded by large amounts of fat droplets. Francisca isolated the vein and tied it to cut it off. It was then colored with a marking pen to indicate and prevent twisting. She also closed off and removed smaller veins that branched from the larger vein and cauterized them to prevent excessive bleeding.
Once the vein was isolated they flushed it out with a heparin/saline solution (weak heparin). Since the inside of the vein is very thrombogenic, it must be coated with weak heparin to counter these effects to prevent blood clots. There was another incision made medial to the first incision to find the arterial target. After isolating the artery and making a small incision on the artery the vein was looped under the skin to act like a bridge onto the arterial side. Francisca quickly sewed the vein into the artery. There was a discernible pulse within the vein and since veins do not normally hold pulses, this signified that the surgery had been completed successfully.
The turnover time for each surgery seemed to be 20 minutes for the same OR room so I decided to use this time to quickly eat my lunch and went back to OR4 for the next scheduled surgery.
This next procedure was a port-a-cath. It was a 54 year old male with metastatic rectal cancer. Once again this procedure required fluoroscopy and so wearing a lead apron was required. Kara came back to the OR and they (Kara and Dr. Harken) used an ultrasound to search for the carotid artery and jugular vein. This patient was not fully knocked out from the anesthesia, as they used a different form compared to the other cases I saw that day. The anesthesiologist nicely explained that they were using Ketamine and Propofol which induces a dissociative state. Initially it was a little difficult to see but they were successfully able to get the catheter in the vein. The anesthesiologist kindly allowed me to stand in her area where I propped up two stools on top of each other to be able to see more clearly.
Francisca then injected some lidocaine to where she was making an incision, right below the right clavicle. She then continued to insert a rod connected to a white tube. A small device was inserted where the incision was made (below clavicle). They removed the thin, long metallic catheter and inserted a valve like device simultaneously and inserted a tube into the valve. The procedure was a little confusing as I did not understand what was occurring or what it was for. I later asked Dr. Harken and he explained to me that the purple device being put in was a port for chemotherapy patients as the arteries starts to deteriorate when being used for chemo for so long. The white tube connected to the device goes straight into the right atrium and allows the drugs to flow directly into the heart.
I was so grateful for Dr. Harken allowing me to see so much during surgery. I feel like this opportunity was very rare and everyone on the surgery team in OR4 were all so nice, my first day of OREX was truly an incredible one. I finished my day at 5pm totaling to an 8 hour day and boy was I pooped. I thanked everyone for allowing me to observe their work and I happily went home. If you read all of my rambling, thank you! and yay to a great first day in OREX (: I cannot wait for my next day!
Posted on January 9, 2016, in Uncategorized and tagged arteriovenous fistula, ejection fraction, fluoroscopy, healthy hearts clinic, ICD placement, port-a-cath. Bookmark the permalink. Leave a comment.